Swashbuckler approach and surgical technique in severely comminuted fractures of the distal femur

Background: Multiplanar severely comminuted type C3 distal femoral fractures present many challenges in terms of surgical approach and technique of fixation, which eventually reflect on the final outcome. This prospective study investigates a possible strategy to overcome these problems and hence improve the outcome by using a modified anterior approach to anatomically reconstruct the articular surface, followed by rigid fixation and an early aggressive rehabilitation program. Methods: Nine polytraumatized patients with closed C3-type injuries were included; seven were men, and the mean age was 33.4 yr. The cause of injury was road traffic accident in seven patients and a fall from a height in two. Five patients underwent surgery during the first week and four during the second after injury. The procedure was an anatomical reconstruction through a Swashbuckler approach, preserving the integrity of the quadriceps muscle and extensor mechanism. The mean follow-up was 17.6 mo (14-26 mo). Results: All patients had good clinical and radiographic healing without nonunion or malunion. Mean radiographic healing time was 19.2wk. Clinically, three patients had excellent results, four had good results, one had a fair result, and one had a poor result. No patient developed skin necrosis, deep infection, or implant failure. However, the two patients with a fair and poor result had limited knee flexion to 85 degrees; one required subsequent quadricepsplasty. Conclusions: The use of this anterior approach facilitated anatomical reconstruction of severely comminuted type C3 distal femoral fractures while preserving the integrity of the quadriceps muscle and extensor mechanism. This procedure had fewer than expected complications, had a favorable clinical outcome, and avoided future interference with any total knee arthroplasty surgery.